Privacy Information

EDI Rules

HIPAA electronic data interchange, also known as HIPAA EDI, is the electronic transfer of information in a standard format. It allows for the exchange of information in a fast and cost-effective way.

According to the Department of Health and Human Services, HHS, this lack of standardization:

makes it difficult and expensive to develop and maintain software; and

reduces the ability of health care providers and health plans to achieve efficiencies and savings.

Transferring information in an electronic fashion can eliminate the inefficiencies of handling paper documents, as well as providing an opportunity for both parties to reduce administrative burden, lower operating costs, and improve overall data quality.

In order to ensure the efficiency of this process, HHS has adopted record formats for certain transactions. These record formats are called "standards". The standards specify the format, data content and code sets to be used for each transaction. Covered entities, which are required to use these standards, are prohibited from altering these standards when exchanging data.

By using these transaction standards, we now have the ability to exchange information in a fast and cost-effective way.

The HIPAA EDI Rule defines 3 groups, referred to as Covered Entities that must comply with the HIPAA EDI Rule. The Covered Entities are Health Plans, Health Care Clearinghouses, and Health Care Providers.

We are a Health Plan when conducting business activities for certain of its products, called "covered products." The majority of our products are exempt from the HIPAA EDI Rules. For example, Long Term Disability (fully insured and self insured), Short Term Disability (fully insured and self insured), Life and Accident coverages are all excluded. Products that are "covered products" include long term care, expense base cancer, hospital confinement, dental, vision or intensive care policies, certain medical coverages and other health plans pursuant to the Health Insurance Portability and Accountability Act ("HIPAA")

We have the ability to conduct the HIPAA regulated transactions with respect to its covered product when required to by the regulation. At this time, we cannot support HIPAA EDI transaction standards for the remainder of our portfolio.

Our response to some frequently asked questions about the HIPAA EDI Rules. Read more

EDI Standards

According to the HIPAA EDI rule, a "transaction" is the exchange of information between two parties to carry out financial or administrative activities related to health care.

HIPAA identifies certain transactions for which there is a mandatory "standard" format and data content, which cannot be changed or altered by covered entities when conducting any of those transactions.

The Department of Health and Human Services has adopted "Implementation Guides" that outline each of the transaction standards. These Guides can be found on the Washington Publishing Company website.

The HIPAA EDI transaction standards are referred to by both a name and a numerical identifier. For example the transaction that is used to support the electronic payment of premiums is often referred to as the 820 transaction standard.

The HIPAA EDI transaction standards that impact our covered products are as follows:

834 Enrollment/disenrollment

270 Eligibility inquiry

837 Claim encounter

276 Claim status inquiry

835 Remittance advice EOB

820 Premium payment

271 Eligibility response

837 COB Coordination of benefits

277 Claim status response

Please click this link for more information on the HIPAA EDI transaction standards that impacts our covered products.

EDI Transaction Standards

Numerical identifier: 820
Transmission of any of the following to a health planfrom the entity that is arranging for the provision of health care coverage payments or is providing health care coverage payment for an individual:

Payment

Information about the transfer of funds

Detailed remittance information about individuals for whom premiums are being paid

Payment processing information to transmit health care premium payments including any of the following:

Payroll deductions

Their group premium payments

Associated group premium payment information

Eligibility inquiry

Numerical identifier: 270
An inquiry from a health care providerto a health plan, or from one health planto another health plan, to obtain any of the following information about a benefit plan for an enrollee:

Numerical Identifier: 837
A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care.

If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.

Colonial Voluntary Benefits products are underwritten by The Paul Revere Life Insurance Company, Worcester, MA, and administered by Colonial Life & Accident Insurance Company. Dental plans are underwritten by The Paul Revere Life Insurance Company, Worcester, MA. Some dental plans are administered by Starmount Life Insurance Company.
The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benefits payable.